Chapter 9 DISCUSSION Since breast reconstruction with the TRAM flap was first described by Hartrampf in 198212, the reduction of the morbidity of the operation has become the goal: the deep inferior epigastric perforator flap is the result of this process decreasing donor-site morbidity at the abdominal region. The rib-sparing technique reduces the donor-site morbidity at the level of the recipient vessels. Malata et al.7 already discussed the tips, advantages and disadvantages of a rib-sparing approach to the mammary vessels: they advise: 1. to keep the intercostals muscle excision medial to 3 cm, 2. to transfix the vein caudally if possible, 3. to judiciously remove the costal cartilage to optimize exposure and facilitate anastomosis or, in some cases, 4. to sacrifice the rib cartilage if really necessary, 5. to keep the intercostal nerve above the vessels, 6. to lose approximation of pectoralis muscle split, 7. to use the standard anastomotic suture technique and 8. to use long-handled microvascular instruments. they conclude recommending this technique. They started with isolation of the mammary vessels in the third intercostal space and in the last cases of their series they used the second intercostal one more and more because in the third intercostal space they sometimes had to remove a part of a rib to have good access to the anastomosis. Moreover, in some cases it was observed that the vein splits into two branches under the third rib giving two smaller veins in the third intercostal space. We analyzed the characteristics of the second and third intercostal space with MRI. The MRIs were made during staging of patients with breast cancer: in the future a preoperative MRI could be used to add information from also above the mammary vessels and intercostal spaces. The second intercostal space is mean 4.4 mm (29%) wider than the third one, giving better access to the blood vessels. In the second intercostal space 138 veins were found and 146 in the third one. Therefore we conclude that in the most cases of variation III and I of Schwabegger the vein divides under the third rib confirming the study by Malata. As a consequence, if the vein divides, usually in the intercostal space 2 only one vein will be present and in the intercostal space 3 two veins will be present. It may be better to use the third intercostal space in case two venous anastomosis are needed. Hanasono demonstrated that 2 venous anastomosis are not decidedly better than one because venous blood velocity is significantly greater after a single venous 159
5. lay-out phd DEFINITIEF_digitaal2
To see the actual publication please follow the link above